2.6 .

Helicobucter
. b cter (so-called ''gastric C.:umpylohacter" ) were
I strains of rlehco a
The firs . . h Robin warren and Barry James Marshall ( I Q82J
· Australia by Jo n
isolated in . t n infection of laboratory pigs, in 1984 Marshah
:\ fter failure of expenmcn s o . . .
f the bacteria isolated from a patient. and soon lhe
himsdf drank the cuIture o . .
. . ,'th achJorhyd.ria developed: gastric d1scomfor1, naus~
symproms of gastr1t1s "'
· . d ·r.c smell from the mouth. Then Marshall demon strated that
vom111ng, an 8 spec, 1
his hel icobacterial gastritis with a 14-clay course of treatment
he was able to cUre ·
with bismuth salts and metronidazole. On the 14th day after infection biopsy did
not shcnv any presence of bacteria in the stomach. 11 was proved in accordance
with Koch's postulates that H. pylori causes gastritis. Further studies in man~
countries had confirmed the role of Helicobacter in pathogenesis of recurrent
ulcers of the stomach and duodenum. Improving the methods of studying
Campylobacter has shown the groundlessness of a systematic position of the
"gastric" Campylobacter. and they were isolated in a separate genus ·
Helfcobacter, including Helicobacter pylori, Helicobacter fenne/liae.
Helicobacter cinaedi and Helicobacter mustelae. The first three types of
Helicobacter arc able to cause lesions in humans. The Nobel Prize in Physiology
and Medicine (2005) was awarded jointly to Barry J. Marshall and J. Robin
Warren "for their discovery of Helicobacter pylori and its role in gastritis and
peptic ulcer disease"

H. pylori is referred to the genus Helicobacrer, the family

Helicobacteraceae, the order Campylobacterales. 24 species of Helicobacrer arc
described, so me O f w h'tc b were previously known under other taxonomic
· names.

Morpboloey. H. pylori is a spiral-shaped with 1 to 3 turns gram-negati~

bacterilllm. A · b . . . . . e coccoid
ging actenal cells lose a typical spiral shape and becom
(type 1) D · . · with adverse
· egenerattve changes in the coccus form can occur
effects of env· . . proper use of
tronmenta.l factors (temperature or pH change) or un
1,lt
~ 7
h 011 , ( ( tYp e :n Cuc cuc; form,; nl 1ypc 2 lo~c en1.ymc 8Ct1 v1ty and
a1111 I •
-,duc u,c copnc ity. lhol r mct olh> lism ici ,edu ced wh ·h
rcrrt . . . • IC ere.,~ '•"<>rablc
hlll'" s fur their prcs orvn uon in the intes tine and ,n the
t
1env onmmt
ex crna 11
,one
•
n"nl "he re they can be trnnsmitted to lhc pcr•mn lt,y the fecal- ora 1 route CJJKc '"
l
c act1vc rorm wh,ch
1
hr ~,om ach, H. pyln , , is again tran sformed into spiral !!hap
is cnpablc of coloni1ing the digest 1ve syc,1 em of a host

Coccus form s of H pi/or, arc of

1 .. ., great imp orta nce for the diagnosis or
infec tion Their pres ence can lead to erro ~
in diagnosis. since these form s ar~ n01

I cultivated. have no characteristic signs in

light mic roscopy. do not produce urease or
g other antig :ns.
l produce it in sma ll amounts , and are capable of expressin
is 2,5-3 .5 µm. The
The diam eter of the bacterium is 0,5-1 ,0 µm, the length
l of the poles ii has I-7
bacterial cell is cov ered with a sm ooth membrane, on one
I lateral and pola r flag ella.

brane and a spiral

The presence of flagella. as well as a smooth cell mem
along pH grad ient and
shape, enables th is micr oorganis m to move in the mucus
lla contribute tC\ the
serves as one of the factors of its virulence. In addition. flage
elial surface of the
aggregation of f J. pylori for thei r colonization on the epith
stomach.
y dens e glycocal )~
The cell wall of //. pylo ri is smooth, an electronicall
nm and with a radia l
(caps ule-like membrane) with a thickness of moru than 40
cyclicity of about 14 nm in 5 ize is dete rmined outs ide of its membrane, it
for the adhesion of H.
COflta.ins carb ohy drate-co ntai ning polymers necessary
s to im excract of
PYiori to the surface of epitheliocytes. H. pylo ri strongly bind
epith elial cells of the
glyccroli pids (sulf.ate<l alkolacyl-glyccro lipids) of the
antraJ Part of the stom ach, whi ch is a spec ific rece ptor
for H pylori and explains

its relationship to the pylo ric stomach.

69
 d have a c11arac1cnsuc c:orKscrew mori·
. oduccs n0 spores an 1 11~
b d. ,
// pylori pr I tc granules have been o serve in a number o f gastric
I hosp1a .
1n
tr11ccllular po YP coted in the cytoplas m wi th the larges t size r
he ranules arc Io o
helicobac1crs. T 8 d vacuole- like, ant.I genera lly regarded as
amorphous an an
0.05 to O.l µ_n,. .rvoir. Those located near the fl agella pole
dp
hC1sphorus resc arc
cnerg>' so urcc an d .
. . . e compact and heterogeneous, an possibly provide
0 02 1101 ,n size, mor . . .. .
smalkr. · · .. f the cells. Recently. studies of lcrnt,n m // /J) lo,
' re uired for 111ot1ltty o . . . ,
energ) q . ,' ld-t e strai.n grown m an tron-nch envi ronm ent.
81 In a \\ I yp
showed tl, t •ning iron coul db e d etecte d .
cytoplasmic aggregates con at
. Th mes of two strains have been completel y sequenced.
Gtneucs. e gcno
. , d J99 The 26695 genome was 24kb larger than the J99. bui
H pylori 2669 ~ an ·
both of th e genomes had GCo/o of 39%. The chrom osome of the organism
• genes that encode the urease gene cluster, cytotoxins in the membrane
contams ·
and the cag pathogenicity island . 1n 1989, CagA gene was found and identified
as a marker strain of the risk. of peptic ulcers and gastric cancer.

Helicobacter pylori are capable to uptake DNA from other H. pylori. Due
to the uncertainty of strain linkages. recombination occurs because of the
repetitive DNA sequences, which allows high frequency deletion and
duplication and mismatch in-between the strands. Lack of mismatch repairing
can increase in freq uency of random variation but it can also convert the gene
whfoh can bring down the diversity of the organism .

Cultivation. The most favorable conditio ns for the life. growth and
repro.ducrion of the microorganism are: tempera ture + 37 °C and p H of Lhe
medium 4·0· 6,0, although they survive at pH 2,5. In the course of evolution. lhe
bacteria] cell acquired 'tal h . . .
. vt P ys1olog1cal properti es that enable it to function
actively under "unfavorable" c d't•
on I ions.
Biopsy mate · J ti . • fi e
an .b. . . na or the isolation of H. pylori must be obtained be or
ti Lotte th erapy, or if th · . .
b. e prevtous treabnen t was meffect1ve. Before 0 btaioing
iopsy material it is also and
recommended to stop taking bismuth drugs
70
antibiotics 14 days before. Bacteriologi ca l stud of .
. . y H. pylori does not exclude
other diagnostic methods, at the same time negat' • .
. . 1
,ve resu t ot raprd urease lest or
other methods of d1agnost1cs do not exclude the •b·i·
pos s, 1 lly of isolation of th'
. I . IS
pathogen by bacteno og1cal method. S,ince H p,uf · b
. ,, ori can e spread over the
gastric mucosa in order to increase the sensitivitv 0 f' th th .
~ e me od during the
endoscopic examination, two biopsy samples from d1e antrum (2-3 cm from the
pylorus on the front and back) and two from the body of the stomach (JO cm
from the cardia along the large curvature). Taking biopsy material is processed
from places with the maximum expressed hyperemia and edema. Taking
material from the bottom of ulcers and erosions, and also from their edges is a

mistake, because they do not have epithelial cells possessing the properties
necessary for the adhesion and colonization of H. pylori.

Four biopsies have to be immediately placed in a transport test tube. ff the

time from taking the material to delivery to the microbiologfoaJ laboratory does
not exceed 6 hours, a sterile, tightly closed test tube with 0,5-1 ml of phosphate-
saline buffer must be used. If delivery takes 6-48 hours, commercial transport
media arc used as a transport mediwn (for example, Porthagerm pylori.
BioMerieux). Storage and transportation of samples is carried out at tcmperarurc
+40 °C in a dark place (container). If you need a long-term storage (up to 6
months), biopsy specimens can be stored in 20-::!5% glycerol broth at the
temperature of -70 °C, however in tbjs case the viability of H. pylori and the
probability of a positive bacteriologicaJ test result are reduced.

To separate bacteriaJ cells from the gastric mucosa, biopsy material before
inoculation on nutrient media is homogenized. 2 drops of a homogenized
solution are placed on the surface of blood agar and selective (for example,
Pylori agar, BioMerieux) nutrient media. The dishes are immediately placed in
an anaerobic container, in which a microaerophilic am,osphere is created {Oz-
5%). The Petri dishes are incubated in a thermostat at the temperature of +35-
+37 ° C and humidity of 95%. Results are checked after 4 days. H pylori forms

71
 h lf1'1n~rarcnl . 11irn ilar 10 "clew drn p,•
I) r,c, of
" c,,1,,n> •
~mnll round, smool .
• 1
, mm 111 tho uh~ enl r of ~'I!"~o r gro w1h the ., h
Ku ~hmi •~
die d111mctt r ol •
up 11, I 0- 14 da, ~
rontr1f~~. // p vlm l produce h1vh ly IIC II V
' ,,.,,
Rtnrhcmlc • I P ,.
,pha~
ucinac;c, 0 ,id njc , hcmolysin , olkollnc ph 11 ,c. llJtn"',
urt'ac;c, c11t11ln~c. m
hn~ phata1, i:r ,1, ,
fi sc • nlcohol dchyJm gcnnsc. gh1co1ulp
i,:lu iann 1trans era.
• ·dro chl onc ac,d secrct1on inhi bitor protein . num cr'lu ' a,~11
..n.
c
ph,,cph l,hpa~c. 1l)
.
f
leto n cell membrane, lemm m, cholesterol), C}'lo to xin ~ o pr .•
Ico the cym~k e ·
norurc. c1c.
activi ty H P}l n r, doc; ·a
\\'ith such a wide spectrum of enzymatic
s. \,fctabolism of the bactcna, ~.
cc,ntain cni ) mes that m<'taboliLc carbohydrate
hy the energy release d b) the utiliza tion of tricarboxylic acid, ar:d ,
~ pro, ided
1

am ino acids. but not carbohydrates.

protec t them selv es fro m hos tile env ironmental innuences. bat:ten
To
n surfac e attache d com mu nities des cribed as "bacterial b1olilms "
ofte form

Antigenic structure. H. pylori has a com

plex composition of prot1::tn llr.J

ride antigens. Am ong them the re are the rm ostable 0-antig.en anli
polysaccha
nno labile acidic polysa ccharid e antige n, wh ich in its properue-s .:-an
specific the
be referred to the group of K-antigens.

Flagella enables H. pylori to move in gastnc J

lllCI.' ilD.:
Virulent factors.
layer. II. pylori is able to attach to the plasmolemma of epithelial 1:elb 1.•'
mucus
Lhes i: .:ell •
!hest0mach and des troy the components of the cytoskdet on oi
II PYIon· produces urease and catalase. Urease cleave s urea. contain e =-- n,
d ·10 ·"'~e

of the env ironm ent of the n,icrobe and pro tects 11 fror.i
juice. which increases pH
the- acidic env ironm ent of the sto ma ch. // 1" 1 r, ,,
!he bac teri cidal action of 11''1
. , II "
able to suppress . . gocYt 0st ,
some immune rea ctions, in particular pha
1·1 I •di, Jt"
pro duces dh · . teria to ~p ilhe " " ·
a e5ms that pron1ote the adhesion of bac
hinder their pha y1.0s1.s by po lym orphonuclear leukocytes.
goc
 Epidemiology. The overall spread is higher in developing countries and
also varies in different regions of stales . Between rich urban population and
rural certain difference may also be observed. The principal reason for th is
difference can be- socioeconomk difference between populations. Lack or
appropria1esanitaryconditi ons,safedrinkingwatcr, basicconcep1so fh ygiene,
limitcddiclanda largepopula1ion can play a certain role in high preva lence of
infection. So, the global frequency of H. pylori infection is more than 50% of
the world's popula1ion. In genera l, scropositi viry to H. pylori progressive ly
increases with age

Pathogenlcity. The source of infection caused by H. pylori is a human - a

sick or carrier. H. pylori can be found in sali va and feces. Oral-oral roule of
infec tion transmissi on is realized with gastric probing and fibrogastroscopy in
cases when imperfect methods of disinfecti on arc used for sterili1.ation of
endoscopes and probes. It is not excluded that H. pylori enters the body wi1h
microaerosol. which is fonnedduringconversati on or cough

Infection with H. pylori usually occurs al young age. However, disease

usual!ydevelopsonlyafter scveraldccades. Ouringthislongincubationper iod.
thehos1develops an immuneresponsetothepathogen. Jmmunereactionsare

~~d/C.l] :::: :::::::~::

·~,~~ ,·.t~~-,;:; ;:,~ .gastricc::::i:: ~y/o:;:
rIIUF{i·~
' ) , , \ . , , ) ) _ , , _;,)[ ,· · ' J ofthedisease.

I H

as• rule, is accompanied by

--~ ~-l-,i ~
1 the development of active
chronic &astritis , ~h sometimes progresses to diffuse atrophic gastritis.
 ,, c-,r.r, onl~ n ccr111 in pro purti~~ o f , in fec ted p111 icn t~ hav, chnic~11
'tnili.:-anl s} n, p10111s or1hc disrill?C I hcsc mclud ~ peptic ulcer of 1he ''°"1111.'.
~d Juodenum. gM lriC ndcnocnrc inomn and MAL1 - lympho ma

Rri1 limtion of pnihogenk factors o f // pylori !riggers a I\Un, t,.., ,,r

mf!'ht1nisms of the pathoge nesis o f the infeclio.n : d estruct1 ~e proceno on 11 •
mokcular. r:cllulnr and tissm· 1c ,•c ls. cytotox ic effec ts. impai red 1ecre11,,r
rompcnsatory gland reactions. an intcn~c innnmmatory reaction \>oJ!~

prt'doniinancc of ncuirophil infiltrel io n and o large nu mber of plasma cells in lht

mu.:-osa.secrc1ion of lgA
L,borato'1' dl,gnosrics. The interest of practical doctors 10 helicoba~t~,
infr.:tion promoted 1ht development of many different methods of its dia~ os 1~

\\hi.:hindudc thcfollowing:

1. Bacteriological: - microscopy of bacteria in smears -imprints: - isolauon

and identification of// pylori.

2. Serological: - com plement fixatio n reaction: - the reaction of indire,;1

hemagglu1ination: - enzyme linked immunoassay (ELISA): - immunobloning: •
detection of // pylori in stool: - detection of II. py lori in saliva.

3. Morphological : - C)1ological - the detection of f-f pylori in a biops)

with Romanovsky-Giemsa, Gram and other staining; - histological

4 Biochemical: - urease lest with biopsy specimens : - analys is of exha!rd

air (aerotesl, in which 1he conlen1 of 13 C or 14C is detem1 ined in the exhakJ air
after lhe patieni has taken the urea inside, previously labeled with the sp,:-: i!icd
radioactive isotopes)

S. Molecular-genetic: - polymerase chain reaction (PCR).

The bacteriolog ical meth od enables to cultivate H. pylori usinf t-j,,rs~

th
: ~ .; les of . e SlOmac h. The spec ificity of th is method is !00%. lhe fr equ ,ii~~
PYiori pure culture isolation according to different authors varii:s fron1:.
 10 91%. The strains obtained can be examined
for resistance I0 •
drugs. which currently represems the main proble . ant,bactcnal
. . m of treating th'1 . .
Without the bnctenological method, it is not 'b ~ 1nfec11on
. . poss, le Lo plan an
rrentment regimen for patients. since the . optimal
. mn,n reason that d
. . . 'b' . .
eradication rate 1s ant, toltc resistance of fl. py lori wh· h re ucc,· the
•
time only by this 1nethod. ' IC can be defined a1 thi\

To identify H. pylori, Gram stain (under the m·

icroscope, Gram-negative
rods are detected in the presence of f-f. pylori' and b' h . . .
, em1cal typing 15
1oc
performed (urease, catalase, oxidase activity H p•v/or,· do ~
• · ; es not 1ennen1
glucose, does not produce nitrates, does not form indole). The complexi ty and
high cost of perfonning the bacteriological method restrict its use, despite lht>
undeniable advantages. Several attempts have been made to cu ltivate H. pylon
from gastric juice, but this bacteriological method has not been widely used.

For the detection of urease, which is indicative of the presence of H.

pylori. various bioche1nical techniques have been proposed. In diagnostic media
ii' is necessary to include urea and indicator, place a gastrobioptate; if a product
of urea hydrolysis (ammonium) accumulates in the medium • pH of the medium
changes and the indicator changes color. Urease test is simple in perfonning,
does not require special ,: ...~lification of medical personnel. relatively
inexpensive, enables you to quickly get a response (depending on the
modification of the test, the result can be obtained in a few minutes, but mostly
after 24 hours).

At present, there arc commercial urease tests: "CLO-test", "Dc-Nol-tcst".

''PyloriTek", ''CUT-test", "HELPIL-test", ''Campy-tesc", etc. The sensitivity of
these tests ranges from 65 to 95%, specificity - from 75 to 100%.

Aggression of H . pylori and colonization of the stomach cause 8 systemic

.... _11une response, resulting
·l"U.1 . m . antibodies
. . lgA, Ig M, IgG that can be detected by
seroIog,caJ
. • al method
methods. The most common serologic · for diagnosis of
H. PYiori infection is indirect ELISA. The sensitivity of the method ranges from
 '"'"' 1~ l(t• 1011• 11 I 11\J\ I~ 1hc m11,1 ,111tnhlc rnettw
l) Si' ~f'~1til II) ,cJ f •
87 tft o 1, on,t ,,recn111g
al , 1111
J1."llllll I"[lll
rr• h ..,.,.tcri,cd bv the prc,~11'-c o f c•ARA "e
\ ,n1knl c.11-a1nc &rt t:. "' " ~ •
I fi I I " nc •k ,1
ted protein and 11 s oun< n pa11ent• Nllh •
IOll"\' IC• OSS0C l1' II"
rl'{'(fu~rc • ' ' • Pl ISA method allows detecting anllhod,c, 10
"l"'ntllCh cancer. o,.
1l«r Ill' d • ,. r . ·rh d'
~ rotrin in the ,cruni o pnhcnt.s. c iagnos1,,. ~n,11•11
'\1\"ll (>, t\'.:•llSS~"<l l81cJ p /
· d c1ion of onm,bodles 10 the CngA protein of // (Tj/,;r, ,, o/.
.:-1 1ec.1 c;yc1ems for rte
Ioo.... ~recific1f) is 76-94o'o
. 1. ..,..,.looical methods for the diagnosis of H. fl) /or, tnfectir•
One Cl f mr 5.., v e

,Htb b,g.h spc:-c:1 Ii,c1' t) , is \Vcstem-blotting. With the help of 1h1_s mctfw
, strains are now divided into 4 serotypes dcpcodin11 00 :h·
Hrllcobacter fl) Ion e •

production of Vac•\ cy1oto>. in and cytotoxin-as~ociated protein Cag \ ty,e ·

tCagA --. \"acA -'- ). 1ype la (CagA +. VacA -). type lb (CagA-. VacA +), r, pr ';
1CagA-. \ 'acA-).

Recent!~. qualit} tests have been developed lo determine antibodies 10 HP

thru cnn be perfonned "at the patient's bedside". They are based on l!Uc.\
agglutinat1on or solid phase ELISA and reveal lgA antibodies lo II pylori To
auT) out the study, a drop of blood taken from the finger is needed. lhe result u
read oul in II few minutes. no additional reagents are required. The d:ag111,s:i,
sens itI\ ii} of such Lests is 94%. Specificity is 98%. Due to the unique simplicit;
of implementation. these methods are indispensable in small ho:-pituls '"
outp,aucnt chnics. where the need for diagnosis is detern1incd by single anal~lt>
or io the office Of ti1e f:amity doctor. In 199:8, test systen\5 appearl'.' d for tM
quantitau ve dcte · · · · · ELIS\
rnunation ot H pylori antigen in feces of patienlS using
which have great p . T . h ds 10 !he
rospects. he d1agnos1ic sensitivicy of such md 0
detection of H 1 . .
PY or, 15 8R ,9ulo. Tho specilici1y is 94,6%.

Treattneot C . . . i~n, rcr

· urrenlly, there 1s a large number of therapeuuc regull
the lrcatmen1 of // . . . ·c:t ~tc.'11
· pylori tnfect,on, but optimal therapy has 0 0 1 ) .
develope·' Th .., ot
u. e basis for the 1· s the us•
treatment of I./. py lori infeclion
76
 which include: co lloidal bismuth
combinnlions of three-compo nent therapy.
(or tinidezole) : omeprazole (or
subcitn:te + tetracycline + metronidazo le
le: omcprazole (or pantoprazole )
pantoprazole) + clarithromycin + mctronidazo
of 4 drugs • quadrotherap y
+ amoxicillin + clarithromycin. The combination
+ tetracycline + mctronidazole) is
(omeprazole + colloidal bismuth subcitrate
considered as reserve therapy.
eadingscien titiccenters
Eradication therapyis notalwayss uccess ful.Forl
indicatorof thecffectiv encssof
eradication ofH. py/oriabov e80% is a good
thm,py.
studies. the following
Prophylaxis. Based on the results of recent
measures may help to reduce transmission of
H. pylori bacteria:

espec ially with food

• Practice good hygiene and hand washing.
preparation
symptoms that m11y be
• All parients with chronic gastrointestinal
tested and treated 10
associated with H. pylori infection should be
prevcntexpo suretofamil ymembcrs.
• Maintainpropcrnutrition .
in developing
• Support policies to improve living conditions
countries

2.1.P:uudom ona:i
rod•shaped bacteria with
Pseudomonads are Gram·negative, aerobic,
in damp biotopes. The most
~idesprtad occurrence in nature, especially

;:::::::;::
1
::;~:::i~~::~cs::,:.~i:i:::~::: ::: :
::;~:·:~:a:;::::~:~::~:::::::::::::::
 - - - -4.A--
d•·utages and disadvantages of di a~ ostic tes
ting for
Helicobat:ter pylon

I-
7
Advaar.ag, " Diudvantap
,... _J
Tm Mt dtods .. E."<pensive and requires
II [xc elk nt Sen si1ivit) and
Ris lO I~ sptri Iicit) i nfras1ructut\! and trained
personnel
,, -1
''I/ lne-.:pensl\C and prov1dt's rapid
resul ts E.-.:cclletll specificity and I
c;;ensin vuy signitican tly reduced
in posr- t1eaunent scni 1111
II vel) good senSftiviry in proper!) I
selt'Cled patierns
l L1 --
i E1cellen1 specificity Al l~) C."< pell)lv t. difficult to perfoon.
Cu lw rt II
determination of antibi otic and nOI widely available
! scnsitt YIUdi
k 1
ln~pensive. widely 1V31'1blt Posirivt' predictive value (l'P V)
I A11tibody I
dependent upon background
lrslillJ! 1( very good ncga11 vc prcd1ct i~e
tquan11 tat1\r and •I value (NP \-, fl py lon preval ence No t
11uili1a1h e) rCl01n111endt:tl 1tf1e, ll.Jlylort
therapy
= = = = = = = = -: := = ,= ---=-= =
=, ===
= = = -= - -= tel l\ c H.p ylu r,
,1 ld1;111ifies
I 'r,1 br.-ath
tab ~ infccu011 E.,ccllcn1PPV and
NP \, ~ardles.~ of H py u1
p~ ale nc e.
r-c:--=---=--- - 11:- - - -"'"'-~=-=--~ - --,1-
I '

Pol yclonal test less well

Ii H,,ylnr,
Identities active ida led than the IJ~ r in the
,
infccti oo. E:«:cl lent posi th~ illd ~ "al
post-<r earment setting.
1 11«•1 ••filu jj negativ~ rredicti\·e value< r, Monoclonal lCil appears rdia blc
la t ft regard le~ of H.p_) /or, f bdore and after antibiotic
1 Pff'Valen~ Useful before and
therapy. UnpfeuanmtSS
afrcr H.pylori thc nip y
' ~ 1ssoci2:ted with col lecting stool
l I ... ,,,,,,